Volume 101, Issue 9,
September 2011

South Africa recently lost a valiant woman, who was a nurse. The above quotations, attributed to Florence Nightingale, the founder of the nursing profession, might equally well have been uttered by Ma Albertina Sisulu.

To the Editor: Our article compared and contrasted the ages at which South African children could consent independently to various health-related interventions at the time of publication and when the Children's Act (No. 38 of 2005) became fully operational. As this Act has been fully implemented, all the ages of consent that we indicated would come into operation are now in force. We would like to bring this fact to your readers' attention and ask that they read the original article together with this letter.

To the Editor: The algorithms in the excellent article in the SAMJ for coping with bleeding at caesarean section (CS) cannot be faulted. add some further comments.

With 2 years of internship, it should be possible to ensure that all trainees are allowed to opt for a 6-month attachment in Obstetrics and Gynaecology if they intend to work in peripheral hospitals, so they are able to do a sufficient number of CSs under supervision before they go to their new posts. My experience over many years with attempting to make interns competent during 4-month rotations was frustrating. They always moved on before I felt they were ready.

To the Editor: Maurice Henry Pappworth (1910 - 1994) was a controversial figure. A lifelong outsider, he chose an unconventional career path as a private medical tutor rather than accepting anything less than his first job choice - a consultant post in a London teaching hospital.

Cause of death statistics are an essential data source for monitoring the health of populations, identifying health priorities and planning health service delivery. The case for improving the quality of cause of death statistics for South Africa (SA) has been echoed for the past decade.

Akhenaten was a unique pharaoh in more ways than one. He initiated a major socio-religious revolution that had vast consequences for his country, and possessed a strikingly abnormal physiognomy that was of note in his time and has interested historians up to the present era. In this study, we attempt to identify the developmental disorder responsible for his eunuchoid appearance.

Our children grew up under the guidance of Marina Petropulos as understood and interpreted by my conscientious young wife. I, as a young medical practitioner, played second fiddle to this doyen of all knowledge regarding baby and child care.

Prostate cancer is the most common cancer in men in the UK, accounting for nearly a quarter of all new male cancer diagnoses and around 12% of all male cancer deaths. Based on a similar time period, incidence rates in the USA are even higher at 56.9 per 100 000 men for all races and 234.6 per 100 000 for black men. One in 6 American men are at risk of being diagnosed with cancer of the prostate during their lifetime.

There are limited data on the temporal relationship between the regional introduction of multidrug-resistant tuberculosis (MDRTB) treatment and the subsequent development of extensively drug-resistant TB (XDR-TB). The first XDR-TB case in the Western Cape province of South Africa was recorded in 1992, approximately 5 - 7 years after the regional introduction of MDR-TB-like treatment. Between 1990 and 2002 we identified 48 patients with XDR-TB in the Cape Metropole region of the Western Cape province. Patients were predominantly HIV-uninfected and median survival was 10.8 months. XDR-TB has therefore been present in the Western Cape at least since 1992. These data inform public health policy relevant to the introduction of new anti-TB drug regimens.

The use of retention gifts in clinical trials has been controversial, with some ethicists maintaining that such gifts represent undue inducement to the trial participants. A study was conducted at TREAD Research, a site-managed organisation based at Tygerberg Hospital, in which 302 participants completed a questionnaire that focused on their opinion with regard to such gifts. The results suggest that these gifts do not influence patients to participate in a clinical trial or influence them to remain on a trial should they wish to withdraw. However, they do act as a useful motivational tool and trial participants appreciate them.

Objective. We aimed to evaluate the presenting features and treatment outcome of prostate cancer in men aged <50 years, in a region where prostate specific antigen (PSA) screening is not readily available and most men present with symptoms.

Methods. We analysed the data of 1 571 men with prostatic adenocarcinoma treated between January 1997 and December 2008 at our institution, a tertiary level public sector hospital serving a largely indigent population. Statistical analysis was performed using Student's, the Mann-Whitney and Fisher's exact tests where appropriate (p<0.05 accepted as statistically significant).
Results. Of 1 571 men, 47 (3%) were aged <50 years. The group aged <50 years, compared with that aged >50 years, had a significantly greater proportion with poorly differentiated adenocarcinoma (53%), locally advanced (stage T3 - 4) tumours (56%), haematogenous metastases (75%), significantly higher serum PSA at diagnosis (mean 621, median 74 ng/ml) and shorter survival.
Conclusions. Men aged <50 years presenting with symptoms owing to prostate cancer had significantly higher-risk disease, higher mean PSA, and poorer prognosis than men aged >50 years. To diagnose prostate cancer at a potentially curable stage in men aged <50 years, it is necessary to initiate baseline PSA testing at age 40 and 45 years, and to select high-risk men for PSA surveillance in order to diagnose potentially curable cancer in those with a life expectancy >20 - 25 years.

Background. Obesity and undernutrition are common in South Africa and influence the health outcomes of people living with the human immunodeficiency virus (PLHIV). Aim. To describe the anthropometric changes and perceptions of body weight in adults initiated on antiretroviral therapy (ART).

Methods. A cohort of 230 PLHIV was enrolled at an HIV clinic in Durban. Changes in their body mass index, and waist and hip girth were measured 6-monthly in the 12 months following initiation of ART. Data on demographic and socio-economic variables, CD4 counts, opportunistic infections and drug regimens used were recorded. Perceptions of body weight and desire to change these were ascertained.
Results. Weight perceptions of respondents were incongruent with their body mass index, with the trend being to judge themselves as weighing less than their actual weight. Those wanting to gain weight gained an average of 7.8 kg - 2.8 times more than those satisfied with their weight (p<0.001). After 12 months on ART, there was a statistically significant increase in anthropometric measurements (p<0.001) with 43 of the 110 women having waist circumferences that increased their risk of cardiovascular disease; the incidence of lipodystrophy was 35% (62/177) (95% confidence interval 27 - 42%), 36% (64/177) were overweight and 22% (39/177) were obese, compared with 21% (49/230) and 12% (28/230) respectively at baseline (p=0.002).
Conclusion. There is a strong association between PLHIV's perception of body weight, their desire to gain weight and their actual weight gain on ART. Lipodystrophy, weight gain and truncal obesity are common among PLHIV after initiating ART.

Objective. To determine outcomes of pregnant women and their infants at McCord Hospital in Durban, South Africa, where dual and triple therapy to reduce HIV vertical transmission have been used since 2004 despite national guidelines recommending simpler regimens.

Method. We retrospectively examined records of all pregnant women attending McCord Hospital for their first antenatal visit between 1 March 2004 and 28 February 2007. Uptake of HIV testing and HIV prevalence were determined, and clinical, immunological and virological outcomes of HIV-positive women and their infants, followed through to 6 months after delivery, were described.
Results. The antenatal clinic was attended by 5 303 women; 4 891 (92%) had an HIV test, and 703 (14%) were HIV positive. The HIV-positive women were subsequently followed up: 653 (93%) received antiretroviral therapy or prophylaxis, including 424 (60%) who received triple therapy. Of the 699 live babies delivered, 661 (94%) received prophylaxis. At 6 weeks 571 babies (82%) were brought back for HIV testing; 16 (2.8%) were HIV positive. After 6 months, only 150 women (21%) were receiving follow-up care at the adult HIV clinic.
Conclusion. Where a tailored approach to prevention of mother-to-child transmission (PMTCT) is used, which attempts to maximise available technology and resources, good short-term transmission outcomes can be achieved. However, longer-term follow-up of mothers' and babies' health presents a challenge. Successful strategies to link women to ongoing care are crucial to sustain the gains of PMTCT programmes.

Aim. To describe NVP decay pharmacokinetics in two groups of premature infants - those whose mothers either received or did not receive NVP during labour.
Methods. Infants less than 37 weeks' gestation were prospectively enrolled. Mothers received sd NVP during labour if time allowed. Infants received sd NVP and zidovudine. Blood was collected on specified days after birth and NVP concentrations were determined by liquid chromatography-mass spectrometry.
Results. Data were obtained from 81 infants, 58 born to mothers who received sd NVP during labour (group I) and 23 to mothers who did not receive NVP (group II). Of the infants 29.6% were small for gestational age (SGA). Median (range) maximum concentration (Cmax), time to reach maximum concentration (Tmax), area under the plasma concentration-time curve (AUC) and half life (T1/2) were 1 438 (350 - 3 832) ng/ml, 25h50 (9h40 - 83h45), 174 134 (22 308 - 546 408) ngxh/ml and 59.0 (15.4 - 532.6) hours for group I and 1 535 (635 - 4 218) ng/ml, 17h35 (7h40 - 29h), 168 576 (20 268 - 476 712) ngxh/ml and 69.0 (22.12 - 172.3) hours for group II. For group II, the median (range) volume of distribution (Vd) and body clearance (Cl) were 1 702.6 (623.7 - 6 189.8) ml and 34.9 (6.2 - 163.8) ml/h. The AUC was higher (p=0.006) and Cl lower (p<0.0001) in SGA infants. Plasma concentrations exceeding 100 ng/ml were achieved over 8 days in 78% infants in group I and 70.0% in group II. The MTCT rate was 4.8%.
Conclusion. Women in preterm labour often deliver with little advance warning. Our study suggests that NVP dosing of preterm infants as soon as possible after birth without maternal intrapartum dosing may be as effective as combined maternal and infant dosing.